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Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. BDCSUTR06_REVISED_060419 1

Printed version of this document is for reference purposes only.

Paper copies of the Provider Survey will not be accepted.

A completed Provider Survey must be submitted via the online web application Blue

Distinction® Portals (BD PortalSM).

Review the instructions below to complete the Provider Survey via the online web

application, Blue Distinction® PortalSM.

All question responses must be entered before you can advance to the next page.

To save your responses, click Save. If you need to edit the survey at a later time, click on Save and Exit. This will save your responses and exit the survey. You must also “Check In” the survey on the Survey Actions tab, so other contacts at your facility can access the survey. Once the survey is complete and ready to be submitted, click on Submit. Close the survey window to bring you back to the Survey Actions screen in BD Portal. Program Materials

PDF version of Provider Survey for Substance Use Treatment and Recovery 2020

Provider Survey Question Numbers

Facility Information 1-17

Substance Use Treatment and Recovery Program Information

Program Structure

Treatment and Recovery Management

Transition and Discharge Planning

Performance Improvement

Providers who bill separately from Facility

Charges

Medication Assisted Treatment (MAT)

Practitioners

18 – 37

38 – 51

52 – 58

59 – 67

68

69

Terms & Conditions Not Applicable

Blue Distinction® Centers for Substance Use Treatment and Recovery Provider Survey

Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies.

BDCSUTR06_REVISED_060419 2

A PDF copy of the Provider Survey is available so you can gather the necessary information

ahead of time, prior to completing the online application through BD Portal.

Note: Facilities must submit an electronic version of the Provider Survey in BD Portal; paper

responses will not be accepted.

Additional program information regarding the Blue Distinction Centers for the Substance Use Treatment and Recovery program are available at: bcbs.com

Please complete all Provider Survey information pertaining to your facility’s current and active

substance use treatment and recovery services for adults (18 years and older). Please be sure

that your Survey responses are complete before submitting.

Please pay attention to all special instructions for formats when entering numerical responses.

Here are a few examples:

Percentages: The response of five percent should be entered as a whole number:

5 % NOTE you should NOT enter this as 0.05

VI FACILITY ADDRESS AND IDENTIFIERS WILL BE PRE-POPULATED IN THE ONLINE VERSION OF THIS SURVEY. FACILITY NAME: ADDRESS: CITY: STATE: ZIP:

If any of the information shown above is incorrect, please contact your local Blue Cross and/or Blue Shield Plan representative directly to have the information corrected. Questions in this section that refer to “my,” “your,” “my facility’s” or “your facility’s program” all refer to your facility’s own substance use treatment and recovery program (not the Blue Distinction Centers for Substance Use Treatment and Recovery program). 1. Please provide the following information for the person responsible for completing and

submitting this Provider Survey: Primary Contact Name:

Title:

Phone:

Email:

PROVIDER SURVEY

FACILITY INFORMATION

https://www.bcbs.com/about-us/capabilities-initiatives/blue-distinction/blue-distinction-specialty-care



2. Please provide your facility’s legal contact. This individual may be contacted in the event

there are questions related to potential brand conflicts that need to be addressed.

Facility Legal Counsel/Representative Contact:

Name:

Title:

Phone:

Email:

3. The Blue Distinction Centers for Substance Use Treatment and Recovery designation is

given only to individual facilities (i.e., unique bricks-and-mortar facilities with unique

addresses). Any facility with multiple locations (different addresses) must complete a

separate Provider Survey for each location. Health systems and other groups of multiple

facilities will not be designated collectively.

Is the information submitted in this Provider Survey (e.g., accreditations, program

information, services offered) only for the single facility whose name and address are

listed in the Provider Information Section above, and for no other facilities or locations?

YES NO If NO, please explain.

4. Evaluation of Blue Plans’ healthcare claims data requires distinct provider identifiers to be

present on submitted claims in order to match them back to your facility’s application.

Are claims submitted by your facility to your Blue Plan clearly distinguished from other facilities by using a distinct facility name, distinct Tax ID, distinct NPI, and distinct Plan Provider ID? If you do not have insight on this question, simply answer DO NOT KNOW. This is for informational purposes only.

YES NO DO NOT KNOW

If NO or DO NOT KNOW, please provide guidance on the best method for distinguishing your facility’s claims.

5. Is this facility part of an integrated delivery system that includes other facilities? (If ‘YES’

continue to Questions 6; If ‘NO’ Skip to Question 7)

YES NO

6. If this facility is part of an integrated delivery system, please provide the name of the facilities within your integrated system and indicate which type of substance use treatment



services are available at that specific location. If you are not part of an integrated delivery system, please select “No” in question 5 to skip this question.

Reminder: The Blue Distinction Centers for Substance Use Treatment and Recovery

designation is given only to individual facilities (i.e., unique bricks-and-mortar facilities with

unique addresses). Any facility with multiple locations (different addresses) must complete

a separate Provider Survey for each location. Health systems and other groups of multiple

facilities will not be designated collectively.

The information submitted by your facility will help to identify other potential applicants for

the Blue Distinction Centers for Substance Use Treatment and Recovery program and

inform the expansion to include regular outpatient providers in a future program offering.

Facility Names in Integrated System

National Provider Identifier (NPI)

Detox - Hospital Inpatient, Residential

and/or Outpatient (similar to ASAM

Levels IV-D, III.7-D, III.2D, or I-D and II-D)

Inpatient and/ or Residential

(similar to ASAM Levels IV and III.7, III.5, III.3 and III.1)

Intensive outpatient or Partial

hospitalization (similar to ASAM Level II.5 or Level

II.1)

Regular Outpatient (similar to

ASAM Level 1)

Alphanumeric – Free Text

Alphanumeric – Free Text

Next Row should appear after first row is complete

Note: ASAM is the American Society of Addiction Medicine. For more information on ASAM please go to www.asam.org.

7. What is your facility’s National Provider Identifier (NPI), Federal Tax Identification Number (FEIN) and CMS Certification Number (CMS ID)? If unknown, leave the response blank. [Response Not Required]

National Provider Identifier (NPI)

Federal Tax Identification Number (FEIN)

CMS Certification Number (CMS ID)

8. Does your facility share a National Provider Identifier (NPI) with another facility (or facilities)? (If ‘YES’ continue to Question 9; If ‘NO or Do not know’ Skip to Question 10)

YES NO DO NOT KNOW

http://www.asam.org/



9. If your facility shares a NPI with another facility (or facilities), please provide each facility’s

name(s) and address(es).

Facility Name Main Address City State Zip Code

10. Does your facility share a Federal Tax Identification Number (FEIN) with another facility (or facilities)? (If ‘YES’ continue to Question 11; If ‘NO or Do not know’ Skip to Question 12)

YES NO DO NOT KNOW

11. If your facility shares a FEIN with another facility (or facilities), please provide each facility’s

name(s) and address(es).


12. Does your facility share a CMS Certification Number with another facility (or facilities)? (If ‘YES’ continue to Question 13; If ‘NO or Do not know’ Skip to Question 14)

YES NO DO NOT KNOW

13. If your facility shares a CMS Certification Number with another facility (or facilities), please

provide each facility’s name(s) and address(es).


14. Which of the following substance use treatment services are offered at this facility? Mark

all that apply.

Hospital inpatient detoxification (similar to ASAM Levels IV-D and III.7-D, medically

managed or monitored inpatient detoxification)

Hospital inpatient treatment (similar to ASAM Levels IV and III.7, medically managed

or monitored intensive inpatient treatment)

Residential detoxification (similar to ASAM Level III.2D, clinically managed residential

detoxification or social detoxification)

Residential short-term treatment (similar to ASAM Level III.5, clinically managed high-

intensity residential treatment, typically 30 days or less)

Residential long-term treatment (similar to ASAM Levels III.3 and III.1, clinically

managed medium- or low-intensity residential treatment, typically more than 30 days)



Outpatient detoxification (similar to ASAM Levels I-D and II-D, ambulatory

detoxification)

Outpatient methadone/buprenorphine maintenance or naltrexone treatment

Outpatient day treatment or partial hospitalization (similar to ASAM Level II.5, 20 or

more hours per week)

Intensive outpatient treatment (similar to ASAM Level II.1, 9 or more hours per week)

Regular outpatient treatment (similar to ASAM Level 1, outpatient treatment, non-

intensive)

None of the above

Note: ASAM is the American Society of Addiction Medicine. For more information on ASAM please go to www.asam.org.

15. Please indicate which of the following statements describes your facility's current

accreditation status at the time of completing this Survey: Mark all that apply.

My facility is fully accredited by The Joint Commission (TJC) in the Hospital

Accredited Program. www.jointcommission.org

My facility is fully accredited by The Joint Commission (TJC) in the Behavioral

Health Care Program. www.jointcommission.org

My facility is fully accredited by the Commission on Accreditation of Rehabilitation

Facilities (CARF) in the Behavioral Health Program. www.carf.org

My facility is fully accredited by Healthcare Facilities Accreditation Program (HFAP)

of the Accreditation Association for Hospital and Health Systems (AAHHS) and is an

acute care hospital. www.hfap.org

My facility is fully accredited by DNV GL Healthcare in the National Integrated

Accreditation for Healthcare Organizations (NIAHO®) Hospital Accreditation

Program. www.dnvglhealthcare.com

My facility is fully accredited by the National Committee for Quality Assurance

(NCQA) in the Case Management Accreditation Program. www.ncqa.org

My facility is fully accredited by the Council on Accreditation (COA) in the Private

Organization or the Public Agency Program. http://coanet.org

My facility is fully accredited by the Center for Improvement in Healthcare Quality

(CIHQ) in the Hospital Accreditation Program. www.cihq.org

My facility is in the process of becoming fully accredited by any of the above organizations.

http://www.asam.org/

http://www.jointcommission.org/


http://www.carf.org/

http://www.hfap.org/

http://www.dnvglhealthcare.com/

http://coanet.org/

http://www.cihq.org/



My facility is not fully accredited and is not in the process of becoming fully accredited by any of the above organizations.

My facility is fully accredited from an organization not listed above. Please specify:

16. Please indicate which of the following statements describes your facility’s current

certification status at the time of completing this Survey. Mark all that apply.

My facility is a federally-certified Opioid Treatment Program (OTP). www.samhsa.gov

My facility is certified by The Joint Commission (TJC) as a Behavioral Health Home

(BHH). www.jointcommission.org

My facility is participating in American Society of Addiction Medicine’s (ASAM) Level of Care Certification. www.asam.org/resources/level-of-care-certification

My facility is not certified by any of the above entities at this time.

My facility is certified from an organization not listed above. Please specify:

17. Please indicate which of the following statements describes your facility's current licensure status at the time of completing this Survey. Mark all that apply.

My facility is fully licensed by the State Department of Health.

My facility is fully licensed by the State Mental Health Department.

My facility is fully licensed by the State Substance Abuse Agency.

My facility is not fully licensed by any of the above organizations.

My facility is fully licensed by an organization not listed above. Please specify:

Questions in this section that refer to “my,” “your,” “my facility’s” or “your facility’s program” all refer to your facility’s own substance use treatment and recovery program (not the Blue Distinction Centers for Substance Use Treatment and Recovery program).

PROGRAM STRUCTURE

18. Indicate which age groups are accepted for treatment at your facility. Mark all that apply.

Adults (18-64 years)

Seniors (65+ years)

Adolescents (13-17 years)

Children (<12 years)

SUBSTANCE USE TREATMENT AND RECOVERY PROGRAM INFORMATION

https://www.samhsa.gov/medication-assisted-treatment/opioid-treatment-programs/apply


http://www.asam.org/resources/level-of-care-certification



19. How many patients were admitted to this facility’s substance use treatment program in

2018?

Number of patients admitted to this facility’s

substance use treatment program in 2018 Unknown/Prefer not to answer

# of Patients _____ (whole number only, zero is a valid response)

20. What percentage of patients admitted to this facility’s substance use treatment program in

2018 may be considered as ‘out-of-area’? (i.e. program is not within their home community,

county, state, etc.)?

Percentage of Patients Admitted to Program in

2018 may be considered as ‘out-of-area’ Unknown/Prefer not to answer

% of ‘Out-of-

area’ Patients _____% (whole number only, zero is a valid value)

21. Which of the following substance use, abuse, or dependence disorder(s) are treated at your

facility? Mark all that apply.

If ‘Other’ is selected, please list all appropriate substance use, abuse, and dependence

disorder(s) and, if available, the appropriate ICD-10 Code.

Alcohol Cannabis Cocaine Hallucinogen Inhalant Opioids Sedative, hypnotic or anxiolytic (e.g., Benzodiazepines) Stimulant (e.g., Methamphetamines) Other (Specify: )

22. Does your program facilitate multidisciplinary care (either at your facility, within an

integrated delivery system, or through coordination within a virtually organized ‘medical

neighborhood’ delivery system), to ensure that the patient has timely access to care?

Select applicable responses.

Virtually organized ‘medical neighborhood’ delivery system includes facilities or providers

with which your program coordinates multidisciplinary care without a formal relationship

(i.e. integration, contract).

(If ‘YES’ continue to Questions 23 then 24; If ‘NO’ Skip to Question 25)

YES; Clients with multiple diagnoses (e.g., mental health and substance use

disorder) are managed at this facility by onsite providers

YES; Clients are provided access to multidisciplinary care through an integrated

delivery system or within a virtually organized ‘medical neighborhood’ delivery system



NO; provision of or access to multidisciplinary care is not facilitated by this program

at this time or prefer not to answer.

23. If your program facilitates multidisciplinary care, are the following disciplines available

onsite or coordinated through either an integrated delivery system or virtually organized

delivery system? Mark the appropriate selection in each row.

Discipline Available Onsite Coordinated through either

integrated delivery system or

virtually organized delivery system

Not Available or Unknown

Addiction Medicine

Primary Care

Counseling Services (e.g. patient and family counseling)

Psychotherapy

Case Management Services (e.g. housing assistance)

Rehabilitation

Referral Services to other Specialists/Centers with Expertise in Treating SUDs

Assistance with obtaining social services (for example: Medicaid, WIC, SSI, SSDI)

Domestic violence—family or partner violence services (physical, sexual or emotional abuse)

Self-help groups (for example: AA, NA, SMART Recovery)

Multiple diagnosis coping and counseling (for example: health education for HIV, AIDS, Hepatitis, etc.)

Telehealth/telepsychiatry

24. If your program facilitates multidisciplinary care, does coordination of multidisciplinary care

occur throughout the continuum of care (i.e., promotion, prevention, referral, treatment, and

recovery)?

YES

NO

Prefer not to answer

25. For each type of evidence-based therapies listed below, please mark the box that best

describes how often that approach is used at this facility for patients diagnosed with

Substance Use Disorder (SUD).

If ‘Other’ is selected, please list the title of the Clinical/Therapeutic Approach and, if available, a link to a description/reference.



Clinical/Therapeutic Approach Never Rarely Sometimes Always or Often

Not Used or Unknown

Cognitive-behavioral therapy (CBT)

Contingency management

Community reinforcement approach (CRA)

Motivational Enhancement Therapy (MET)

The Matrix Model

Twelve-Step Facilitation Therapy (TSF)

MultiSystemic Therapy (MST)

Multi-Dimensional Family Therapy (MDFT)

Brief Strategic Family Therapy (BSFT)

Functional Family Therapy (FFT)

Behavioral Couples Therapy (BCT)

Other treatment approach (Specify:_________________________)

26. Does your facility employ any certified addiction counselors?

(If ‘YES’ continue to Question 27 then 28; If ‘NO’ Skip to Question 29)

Certification(s) such as:

Certified Addictions Counselor (CAC)

Certified Addictions Professional (CAP)

Certified Addiction and Drug Abuse Consultant (CADAC)

National Certified Addictions Counselor Level I (NCAC1)

National Certified Addictions Counselor Level II (NCACII)

Masters Addiction Counselor with Co-Occurring Disorders Component (MAC)

YES

NO


27. If your facility employs certified addiction counselors, what percentage of addiction

counselors employed at this facility have a baccalaureate degree or higher from an

accredited institution?

Percentage of addiction counselors employed at this

facility have a baccalaureate degree or higher Unknown/Prefer

not to answer

% addiction counselors with a

baccalaureate degree or higher _____ % (whole number only, zero is a valid response)

28. What is the ratio of admitted patients to one (1) certified addiction counselor with a

baccalaureate degree or higher at your facility?

Enter of number of patients. Decimals are allowed. Unknown/Prefer

not to answer

# of admitted patients _____ #



29. Does your facility employ any trained peer counselors or recovery/peer coaches? (If ‘YES’

continue to Question 30; If ‘NO’ Skip to Question 31)

YES

NO


30. Please describe the training and/or certifications required for peer counselors or peer sober

coaches at your facility.

(Text)

31. Does your facility have at least one (1) certified addiction medicine physician on staff?

Certification in addiction medicine through an organization acceptable to ASAM, such as

American Board of Preventative Medicine (ABPM), American Board of Psychiatry and

Neurology (ABPN), or American Board of Addiction Medicine (ABAM).

(If ‘YES’ continue to Question 32; If ‘NO’ Skip to Question 33)

YES

NO


32. How many certified addiction medicine physicians are currently on staff at your facility?

Number of certified addiction medicine physicians on staff Unknown/Prefer

not to answer

# certified addiction medicine

physicians on staff _____ # (whole number only, zero is a valid response)

33. Does your facility verify benefits and eligibility with the health plan, for substance use

treatment and recovery services, prior to patient’s admission to your treatment program?

YES

NO


34. Does your facility notify or make available, to the patient (or patient’s support system, if

appropriate), the patient’s portion of the treatment costs, prior to admission to your

treatment program? (If ‘YES’ continue to Question 35; If ‘NO’ Skip to Question 36)

YES

NO




35. How is information about the patient’s portion of treatment costs communicated to the

patient (or patient’s support system, if appropriate), prior to admission to your treatment

program? Mark all that apply.

Website

Financial counselor

Coordination with Health Plan

Other (Specify: )

36. Please indicate how your treatment program delivers efficient, appropriate, and effective

flow of necessary patient care information to providers and patients (e.g., use of Electronic

Health Record [EHR]) or patient portal)? Mark all that apply.

Use of Electronic Health Record Use of a patient portal Use of Health Information Exchange (HIE) Other (Specify: )

37. If your treatment program utilizes a patient portal, what percentage of patients are currently

enrolled in the patient portal?

Percentage of patients currently enrolled in the

patient portal Unknown/Not

Applicable

% patients currently enrolled

in the patient portal _____ % (whole number only, zero is a valid response)

TREATMENT AND RECOVERY MANAGEMENT 38. Does your facility use an industry standard assessment and/or screening tool informed by

The ASAM Criteria on all patients, prior to admission, to determine the appropriate level of

treatment and guide patient placement?

YES

NO

39. Please indicate what assessment and/or screening tool(s) are used at your facility. Mark all

that apply.

If ‘Other’ is selected, please list the title of the industry standard assessment and/or screening tool and provide a link to a description/reference. Used with permission from The ASAM Criteria, Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions, Third Edition. Copyright © 2013 American Society of Addiction Medicine (ASAM). All Rights Reserved. Unless authorized in writing by ASAM, no part may be reproduced or used in a manner inconsistent with ASAM’s copyright. Use of the “ASAM” or “The ASAM Criteria” trademarks does not constitute endorsement of this product or practice by ASAM. For information on ASAM copyright and permissions see: https://www.asam.org/copyright-and-permissions

Substance (Other Than Tobacco) Abuse Structured Assessment and Brief

Intervention (SBIRT) Services

Addiction Severity Index (ASI)

https://urldefense.proofpoint.com/v2/url?u=https-3A__www.asam.org_copyright-2Dand-2Dpermissions&d=DwMGaQ&c=aIUDzRSH0GV4AQi9KEcOBQ&r=4jj1ilILIgy0OlHZHz0RjUyo4O0u2QpM4yNBt_Ib6FI&m=gy-iqb2dfWFKu8Q6FZXtWBU54k4OkjffWpc-4DbVQis&s=BfJCzN6tfkpLZU43uAp9ocB_g5WE5E04e-So78zGQkQ&e=



Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) NIDA Drug Use Screening Tool: Quick Screen (NMASSIST) Alcohol Use Disorders Identification Test-C (AUDIT-C) Alcohol Use Disorders Identification Test (AUDIT) Opioid Risk Tool (ORT) CAGE

CAGE-AID CRAFFT The ASAM CONTINUUMTM Assessment The ASAM Co-TriageTM Screening Tool Drug Abuse Screening Test (DAST-10) Assessment/screening tool developed and validated by your facility Other (Specify: _____________________) This facility does not use an assessment and/or screening tool

40. Does your program routinely and systematically utilize a patient and family-centered

Shared Decision Making Process (defined below) for patients undergoing substance use,

treatment, and recovery, which includes both (1) an appropriate, high quality, and objective

decision aid and (2) decision coaching? (If ‘YES’ continue to Question 41 then Question

42; If ‘NO’ Skip to Question 43)

Shared Decision Making

Shared Decision Making is an approach where clinicians and patients consistently discuss all reasonable treatment options, the benefits and harms of those options, and which benefits and harms matter most to the patient, in order to jointly make treatment decisions that are consistent with both the best medical evidence and the patient’s preferences.

Patient-Centered Shared Decision Making aids (e.g., booklet, video) are tools that help people become involved in decision making, by providing information about the options and outcomes and by clarifying personal values. They are designed to complement, rather than replace, counseling from a health care

professional.

One key to success lies in training physicians to help them understand how to facilitate the Shared Decision Making process and to ensure that they appreciate the importance of respecting patient’s values, preferences, and expressed needs. 1, 2 It is also helpful to use a team approach to Shared Decision Making so that the physician’s time is used appropriately. 1 AHRQ website accessed July 24, 2018 https://cahps.ahrq.gov/Quality-Improvement/Improvement-

Guide/Browse-Interventions/Communication/Shared-Decision-Making/index.html

2 Towle A, Godolphin W. Framework for teaching and learning informed Shared Decision Making. BMJ

1999; 319(7212): 766-71.

YES

NO


41. If your program utilizes a patient and family-centered Shared Decision Making process,

please describe how your program implements Shared Decision Making. Select Not

Applicable if you program does not utilize a patient and family-centered Shared Decision

Making process.

TEXT BOX

Not Applicable

https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html

https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html



42. Have your program staff who are responsible for Shared Decision Making received training

in the implementation and facilitation of Shared Decision Making?

YES

NO


43. If your program DOES NOT utilize a patient and family-centered Shared Decision Making

process, please describe how your program involves patients, families, or support systems

in treatment options and decisions.

TEXT BOX

44. Does your program systematically collect information in order to measure and improve your

decision process or outcome quality, which includes soliciting patients on their decision

making experience?

YES

NO


45. Does your program deliver individualized care planning (i.e., a flexible and customizable

treatment plan that meets the unique needs of individual patients, based upon the severity

of their condition and is modified regularly to determine when to transition patients to

another level of care) throughout all stages of treatment?

YES

NO


46. Does your program perform patient and family-centered long-term planning and goal

setting in order to address the continuum of care beyond treatment at your facility? (If

‘YES’ continue to Question 47; If ‘NO’ Skip to Question 48)

Patient and family-centered long-term planning and goal setting

Healthcare providers and organizations are increasingly focused on a transition from provider-centered

instruction to person-centered participation. This is driven by both the recognition of the value of person-

centered care in helping individuals to achieve their desired outcomes1, and in some cases by state and

federal requirements.2 Person-centered care begins with the individual’s goals and respects and addresses

their preferences and needs.1

Techniques often used by health care providers delivering patient and family-centered long-term planning

and goal setting include:

o Identify what is important to the patient through goal-setting discussions

o Negotiate set goals (e.g. break long-term goals into steps, prioritize goals, identify complementary

and supportive goals, document goals using SMART method, etc.)



o Support goal attainment including recognizing and addressing barriers to success (e.g.

housing/place of residence placement; discuss employment or other vocational pursuits, barriers,

considerations, and preferences and facilitate access to applicable resources, etc.)

o Monitor goal attainment (e.g. review goals, including progress and barriers, at regular intervals;

document conversations in the electronic health record for multidisciplinary care team

engagement, etc.)

1. The National Committee for Quality Assurance (NCQA): https://www.ncqa.org/wp-

content/uploads/2018/07/20180531_Report_Goals_to_Care_Spotlight_.pdf

2. Department of Health and Human Resources: https://www.gpo.gov/fdsys/pkg/FR-2015-06-01/pdf/2015-12965.pdf

YES

NO


47. Please describe how your program performs patient and family-centered long-term

planning and goal setting in order to address the continuum of care beyond treatment at

your facility.

TEXT BOX

48. Does your facility have a policy for drug testing that is based on best practices and

standards of care for drug testing (Example: ASAM Appropriate Use of Drug Testing in Clinical

Addiction Medicine)?

YES

NO


49. Does your facility treat opioid use disorder using medication-assisted treatment (MAT) at

this location?

Medication-assisted treatment (MAT) is the use of medications with counseling and

behavioral therapies to treat substance use disorders and prevent opioid overdose. More

information is available at Substance Abuse and Mental Health Services Administration

(SAMHSA) https://www.samhsa.gov

YES

NO

50. If your facility offers medication-assisted treatment (MAT) for opioid use disorder at this

location, please indicate the best description of your approach to MAT. Mark all that apply.

This facility does not treat opioid use disorder using MAT. This facility accept clients using MAT, but the medications originate from or are

prescribed by another entity? (The medications may or may not be stored/delivered/monitored onsite.)

This facility provides detoxification from opioids of abuse with methadone or buprenorphine.

This facility administers and/or prescribes naltrexone to treat opioid use disorder.

https://www.ncqa.org/wp-content/uploads/2018/07/20180531_Report_Goals_to_Care_Spotlight_.pdf

https://www.ncqa.org/wp-content/uploads/2018/07/20180531_Report_Goals_to_Care_Spotlight_.pdf

https://www.gpo.gov/fdsys/pkg/FR-2015-06-01/pdf/2015-12965.pdf

https://www.asam.org/resources/guidelines-and-consensus-documents/drug-testing

https://www.asam.org/resources/guidelines-and-consensus-documents/drug-testing

https://www.samhsa.gov/



This facility administers and/or prescribes buprenorphine to treat opioid use disorder.

This facility administers and/or dispenses methadone to treat opioid use disorder. Other (Specify: ______________________)

51. If your facility offers or coordinates MAT, does your facility coordinate follow-up care for the

continuation of MAT treatment following discharge, by providing facility information AND

scheduling an appointment?

YES

NO


Transition and Discharge Planning 52. Does your facility have a policy to initiate transition and discharge planning, beginning at

the time of admission?

YES

NO


53. When does your facility include the patient and the patient’s support system (as

appropriate) in the transition and discharge planning process? Mark all that apply.

At the time of admission

After the treatment plan is determined

When the discharge plan has been determined


54. Prior to discharge, are outpatient providers and services identified within your organization

and the patient’s local community? (If ‘YES’ continue to Question 55; If ‘NO’ Skip to

Question 56)

YES

NO


55. If your facility identifies outpatient providers or services outside the patient’s local

community, please describe the process your facility uses to connect patients with those

providers or services:

Text box

56. Does your facility coordinate or utilize case management services offered by the health

plan to assist in aftercare planning and to follow up after discharge?



YES

NO

Not Offered/Unknown if offered


57. When an outpatient service or provider is needed, does your provider schedule an

appointment on behalf of the patient, prior to discharge?

YES

NO


58. Please describe steps your facility takes to connect patients (or family, as appropriate) to

outpatient and community services in their home community.

Text box

Performance Improvement

59. Does your program participate in standardized Patient Satisfaction and Experience Surveys

to evaluate and improve care delivery? (If ‘YES’ continue to Questions 60-62 then; If

‘NO’ Skip to Question 63)

YES

NO


60. If your program participates in standardized Patient Satisfaction and Experience surveying,

which Patient Satisfaction and Experience Survey(s) are used by your program? Mark all

that apply:

If ‘Other’ is selected, please list the title of the Patient Satisfaction and Experience Survey

and provide a short description and/or a link to a description/reference.

Consumer Assessment of Healthcare Providers and Systems® (CAHPS®)

CAHPS® Experience of Care and Health Outcomes (ECHO®)

Standardized Survey, Other: _________

CAHPS® Custom Survey unique to your facility

Other (Specify: ____________________)


does your program incorporate Patient Satisfaction and Experience Survey results into

feedback and quality improvement of the system of care?

YES

NO





which patient experience measure(s) do your facility’s Patient Satisfaction and Experience

Survey(s) track? Mark all that apply.

If ‘Other’ is selected, please list the Patient Satisfaction and Experience measure(s) and provide a short description of the measure(s) and/or a link to a description/reference.

Overall client rating of counseling and treatment (e.g., CAHPS ECHO® Survey

Question 28)

Overall effectiveness of treatment at 12 months (e.g., CAHPS ECHO® Survey

Question 29, “In the last 12 months, how much the client was helped by the counseling

or treatment received”)

Accuracy of self-assessment 12 months (e.g., CAHPS ECHO® Survey Question 34,

“Compared to 12 months ago, how do clients rate their problems or symptoms

correctly”)

Other (Specify: _____________________)

63. Does your facility use quality measurement for the substance use and recovery program?

(If ‘YES’ continue to Question 64 then Question 65; If ‘NO’ Skip to Question 66)

YES

NO


64. Which metrics does your facility use to measure the success of your substance use

treatment and recovery program? Mark all that apply

If ‘Other’ is selected, please list the title of the metric provide a short description of the measure and/or a link to a description/reference.

Access to care (e.g., time from first contact to admission to program)

Coordination of care (e.g. time for notifications to multidisciplinary care team

regarding admission, discharge, etc.)

Program completion rate

Relapse rate

Re-engagement after a relapse

Engagement in MAT continuation

Engagement in regular outpatient and/or community based counseling

Other (Specify: _______________________)

65. Does your program incorporate quality measurement results into feedback and quality

improvement of the substance use, treatment, and recovery program and/or the system of

care?



YES

NO


66. Does your facility (and/or providers in your facility’s program) participate in value-based or

alternative payment models? (If ‘YES’ skip to 68; If ‘NO’ or ‘Not Currently’ continue to

Question 67)

Yes, our facility (and/or the providers in our facility’s program) participate or will be

participating in the Patient-Centered Opioid Addiction Treatment (P-COAT) Alternative

Payment Model (APM), outlined by American Society of Addiction Medicine’s (ASAM)

and American Medical Association (AMA)


participating in an Addiction Recovery Medical Home Alternative Payment Model

(ARMH- APM), outlined by Facing Addiction with NCADD (The National Council on

Alcoholism and Drug Dependence) and Leavitt Partners


participating in a different value-based or an alternative payment model (e.g., pay for

value or quality, episode or bundled payment, Per Member Per Month, Shared Savings,

capitated payments with performance targets, case rates with performance targets or

other model (if ‘other,’ please describe model here: ___________________________)

Not currently, but our facility (and/or our providers in our facility's program) are

considering participating in a value-based or an alternative payment model.

No, our facility (and the providers in our facility’s program) are not ready to

participate in value-based or alternative payment models at this time.

Unknown or prefer not to answer

67. What are the top 3 barriers to value-based or APM adoption? Select top 3 barriers:

Provider interest/readiness

Electronic Health Record capability

Health Plan interest/readiness

Government influence

Provider ability to operationalize

Provider willingness to take on financial risk

Potential financial impact to provider

Market factors/Other (Specify: __________________________)

Unknown or prefer not to answer

68. Providers who bill separately from Facility Charges

For all patients receiving services in your facility’s program under the specified level of care, list all providers who may bill separately from your facility’s billed charges in the table below; if none, leave table blank.

For example, this would include laboratory services, drug testing services, clinical therapies, professional providers, and pharmacy charges, etc.

https://www.asam.org/docs/default-source/advocacy/asam-ama-p-coat-final.pdf?sfvrsn=447041c2_2

https://www.asam.org/docs/default-source/advocacy/asam-ama-p-coat-final.pdf?sfvrsn=447041c2_2

https://www.incentivizerecovery.org/

https://www.incentivizerecovery.org/



Refer to the NPPES NPI Registry to find the facility’s National Provider Identifier (NPI) number.

69. Medication-Assisted Treatment (MAT) Practitioners

Please list all practitioners who are permitted to administer and prescribe specifically approved medications (e.g., Methadone, Buprenorphine or Naloxone), to patients within your program at this facility location and/or coordinated through your facility’s organized delivery system; if none, leave table blank.

Refer to the NPPES NPI Registry to find the facility’s National Provider Identifier (NPI) number.

Designation under this Blue Distinction Program will initially only be offered to facilities that provide residential, inpatient, intensive outpatient, or partial hospitalization services. However, the designation may expand to include regular outpatient levels of care and outpatient providers who administer Medication Assisted Treatment (MAT) and information provided by your facility would assist with this anticipated expansion. Once the survey is complete and ready to be submitted, click on Submit. Close the survey window to bring you back to the Survey Actions screen in BD Portal. After you have successfully submitted this Provider Survey, a read-only copy of the submitted application will be accessible on the ‘Survey Actions’ tab in BD Portal under the Provider column. Thank you for your application to the Blue Distinction Centers for Substance Use Treatment and Recovery program. If you have any questions, please contact the Blue Distinction Help Desk at [email protected].

Provider/Facility Name Address City State Zip

Code National Provider

Identifier (NPI) Type of Service

FIRST NAME LAST NAME NATIONAL PROVIDER

IDENTIFIER (NPI) PROVIDER

TYPE

https://npiregistry.cms.hhs.gov/

https://npiregistry.cms.hhs.gov/

mailto:[email protected]



Terms & Conditions

70. ATTESTATION

Attestation for Provider Survey Participation Blue Distinction® Centers for Specialty Care Program(s)

By submitting its response to this Provider Survey for consideration as a participant in this Blue Distinction Centers for Specialty Care® Program(s) (the “Program(s)”), and, if accepted by BCBSA, as a condition to any designation and participation in the Program(s), this provider (“Provider”) represents and agrees as follows: 1. All information that Provider provides in its response to BCBSA's Provider Survey for

consideration as a participant in this Program(s) (including information provided in Provider's

initial response, as well as any additional materials submitted throughout the evaluation and

appeal process for this Provider Survey cycle) is and will be true and complete, as of the date

Provider provides such information to BCBSA. Provider will advise BCBSA immediately of any

material change in such information during this Provider Survey process, and if Provider is

designated as a Blue Distinction Center under this Program(s), for the duration of such

designation.

2. BCBSA may share Provider's individual Provider Survey responses (“Raw Data”) and results

(“Scores”) with BCBSA's member Plans and, pursuant to a confidentiality agreement, member

Plans' current and prospective accounts, for purposes of evaluation, care management, quality

improvement, and member Plans' design of customized products and networks. BCBSA may

combine Provider's Raw Data and Scores together with other Providers’ data to create aggregate

information for public dissemination, provided that such aggregate information will not identify

Provider by name, and will not contain any Protected Health Information (“PHI”), as defined under

the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations

(45 C. F. R. Parts 160-164). Provider’s Raw Data and Scores will not be publicly disseminated

beyond the extent permitted above without Provider's prior written consent, unless required by

law (e.g., subpoena).

PROVIDER attests that it has read, understands, and agrees with the terms set forth in the

Attestation (Section A in the scroll down box, above) and represents and agrees that the

statements therein are accurate.

Provider verifies that it responded to the Attestation above, by and through its duly authorized officer identified below:

Enter Officer’s Name: _______________________________________

Enter Officer’s Title:_______________________________________

Date: ____________

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